Sample Doctor Request for Assessment of Need - IHSS

When you are applying for IHSS protective supervision, your child's doctor must fill out form SOC 821 that indicates your child has impairment in orientation, judgement, and memory. It may be helpful to provide the doctor with written examples of your child's behavior to show their need for 24/7 supervision to prevent injury.

You can use this Google doc as reference, or review the example text below:

[Date]

Assessment of Need for Protective Supervision for In-Home Supportive Services

Dear Dr. [Doctor’s Name],

Thank you in advance for helping us to complete these In-Home Supportive Services forms. As we discussed recently, we are applying for protective supervision for our child, [Child’s Name]. Protective supervision hours are awarded to recipients who require 24/7 supervision to prevent injury to themselves or others due to severely impaired judgment, orientation, and/or memory.

For your reference, I have compiled a list of some of the behaviors we have discussed during our appointments that necessitate 24-hour supervision. Should you have any concerns or questions, please do not hesitate to call/email me. Thank you again.

Sincerely, [Your Name]

Memory:

[Here, provide specific examples that illustrate your child’s memory deficits and how they may result in injury. For example, if the child elopes and gets lost, do they know their address and/or phone number? Do they remember basic hygiene to prevent infection? For older children and teenagers, are they likely to try to cook for themselves, and will they remember that the stove is on? If they get hurt during an activity, will they remember next time and be more careful? Will the child be mindful of medical devices that may be attached to their body? Does the child remember if they have specific medical limitations such as allergies, no eating by mouth, etc?]

Orientation:

[Orientation is difficult to gauge in children, but your examples should demonstrate how your child lacks an understanding of their own position in time and space as well as being aware of others sharing space with them. Do they recognize or understand potential dangers in their environment? Are they conscientious about playing safely around siblings? Do they understand that flailing or throwing objects might cause someone to get hurt? Are they aware of the time of day or day of the week, and do they understand that night time is for sleeping?]

Judgment:

[Provide examples of your child’s deficits in assessing the potential dangers of a situation before acting. Does your child try to leave the house or dart away from you in the driveway? Does the child put items in their mouth that may be a choking risk? Will the child run into the street if not closely attended? Does the child play with items that they don’t recognize as dangerous, e.g. electrical cords/outlets, stove knobs, etc.? Does the child have any sense of “stranger danger”?]

[NOTE: If your child has medical devices attached to their body, e.g. feeding tube, trach, etc., you should also specifically discuss incidents when the child has disrupted their function or dislodged them due to their impaired memory, orientation, or judgment.]

[NOTE: If your child is non-ambulatory, be sure to articulate the ways in which their non-self-directing actions can still cause injury.]